SPINAL

CORD INJURY AND COMPRESSION

Anatomy of the Spinal Cord
The spinal cord, like the brain, is composed of gray matter
and white matter.
The white matter contains ascending and descending fiber
tracts, while the gray matter contains neurons of different
kinds:
Anterior horns contain mostly motor neurons
Lateral horns mostly autonomic neurons, and
Posterior horns mostly somatosensory neurons
participating in a number of different afferent
pathways
In adults, the spinal cord is shorter than the vertebral
column: it extends from the craniocervical junction to
lower border of L1
The segments of the neural tube (primitive spinal cord)
correspond to those of the vertebral column only up to the Major Ascending and Descending Tracts of the Spinal Cord
third month of gestation, after which the growth of the Ascending Tracts
spine progressively outstrips that of the spinal cord. There are 3 main sensory systems entering the spinal cord:
Nerve roots exit from the spinal canal at the numerically 1. Pain and Temperature lateral spinothalamic tract
corresponding levels, so that the lower thoracic and 2. Proprioception stereognosis medial lemniscus (fasciculus
lumbar roots must travel an increasingly long distance gracilis and fasciculus cuneatus)
through the SAS to reach the intervertebral foramina 3. Light touch anterior spinothalamic tract
through which they exit.
The spinal cord ends as the conus medullaris (or conus Descending Tracts 5 ; these systems are important in the postural
terminalis) at the lower level of L1. control of the limbs.
Below this level, the lumbar sac or thecal sac contains only 1. Vestibulospinal tract and reticulospinal tract - facilitate axial and
nerve root filaments, the so-called cauda equina (horses proximal limb movements.
tail) 2. Corticospinal tract and corticorubrospinal tract facilitate distal
limb movements.

Myotomes
Segmental nerve root innervating a muscle
Again important in determining level of injury
Upper limbs:
C5 - Deltoid
C 6 - Wrist extensors
C 7 - Elbow extensors
C 8 - Long finger flexors
T 1 - Small hand muscles
Lower Limbs :
L2 - Hip flexors
L3,4 - Knee extensors
L4,5 S1 - Knee flexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion

Dermatomes
Reflects spinal cord's segmental functional organization
Dermatome
Specific area in which the spinal nerve travels or
controls
Useful in assessment of specific level SCI

NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters 1

 Define the level of injury
LEVEL
hallmark of spinal cord damage!
below which sensory / motor / autonomic
function is disturbed
most caudal spinal segment with normal
sensation and muscle strength of 3/5 or better
absent deep tendon reflexes below the level of
the lesion

Completeness of cord injury
Complete lesion no preservation of any motor or sensory
function
Incomplete lesion any residual motor or sensory function
more than 3 segments below the level of injury

Signs of incomplete cord injury
Any sensation or voluntary movement of the lower
extremities
Sacral sparing preservation of sensation at the anus,
C3,4 perineum, voluntary anal contraction
sensory: top of shoulder All spinal cord syndromes are incomplete lesions
C3, 4, 5 Preservation of sacral reflexes (bulbocavernosus reflex,
motor: diaphragm anal wink) does not qualify lesion as incomplete
sensory: top of shoulder
C5, 6 SPINAL SHOCK
sensory: thumb and index finger In all vertebrates, acute spinal cord concussion or
C7 complete cord transection is followed by SPINAL SHOCK
sensory: middle finger Transient profound loss of all SPINAL REFLEXES below level
C8, T1 of injury (in addition to complete PARALYSIS and
sensory: little finger ANESTHESIA below level)
T4
sensory: level of nipple 1. Flaccid paralysis
T10 2. Absence of reflexes (muscle stretch, plantar,abdominal &
sensory: level of umbilicus cremasteric)
L1, 2 3. Hypotonic paralysis of bowel & bladder (ileus,
sensory: inguinal crease gastroparesis, urinary and bowel retention) priapism.
L3,4 4. Hypotension (not present if lesion is below lower thoracic
sensory: medial thigh, calf level) with anhydrosis and flushed warm peripheral skin
L5 ( poikilothermy). *
sensory: lateral calf 5. Hypotension without compensatory tachycardia (if high
S1 cervical lesion), i.e.NEUROGENIC SHOCK (interrupted
sensory: lateral foot sympathetic outflow vasodilation & bradycardia)
S2,3,4
motor: anal sphincter tone Neurogenic shock
sensory: perianal Triad of
i) hypotension
DISEASES OF THE SPINAL CORD ii) bradycardia
Diseases of the nervous system may be confined to the iii) hypothermia
spinal cord, where they produce a number of distinctive More commonly in injuries above T6
syndromes. Secondary to disruption of sympathetic outflow from T1
Spinal cord contains, in small cross-sectional area, almost L2
entire motor output and sensory input of trunk and limbs -
spinal cord disorders are frequently devastating. Where they come from

Clinical Effects of Spinal Cord Injury
When the spinal cord is suddenly and virtually or
completely severed, three disorders of function are at
once evident:
(1) all voluntary movement in parts of the body below the
lesion is immediately and permanently lost;
(2) all sensation from the lower (aboral) parts is abolished;
and
(3) reflex functions in all segments of the isolated spinal
cord are suspended.

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Clinical Effects of Spinal Cord Injury Pathology of Spinal Cord Injury
The last effect, called spinal shock, involves tendon as well As a result of squeezing or shearing of the spinal cord,
as autonomic reflexes. It is of variable duration (1 to 6 there is destruction of gray and white matter and a
weeks as a rule but sometimes far longer) variable amount of hemorrhage, chiefly in the more
Less complete lesions of the spinal cord result in little or vascular central parts -> traumatic necrosis (are maximal
no spinal shock, and the same is true of any type of lesion at the level of injury and one or two segments above and
that develops slowly. below it)
As a lesion heals, it leaves a gliotic focus or cavitation with
Injury defined by ASIA Impairment Scale variable amounts of hemosiderin and iron pigment.
ASIA American Spinal Injury Association : Progressive cavitation (traumatic syringomyelia) may
A Complete: no sensory or motor function preserved in sacral develop after an interval of months or years - > lead to a
segments S4 S5 delayed central or incomplete transverse cord syndrome.
B Incomplete: sensory, but no motor function in sacral segments In most traumatic lesions, the central part of the spinal
C Incomplete: motor function preserved below level and power cord, with its vascular gray matter, tends to suffer greater
graded < 3 injury than the peripheral parts.
D Incomplete: motor function preserved below level and power
graded 3 or more Transient Cord Injury (Spinal Cord Concussion)
E Normal: sensory and motor function normal Transient loss of motor and/or sensory function of the
spinal cord that recovers within minutes or hours but
Muscle Strength Grading: sometimes persists for a day or several days.
5 Normal strength Spinal cord concussion from direct impact is observed
4 Full range of motion, but less than normal strength against most frequently in athletes engaged in contact sports
resistance (football, rugby,and hockey).
3 Full range of motion against gravity
2 Movement with gravity eliminated Cervical cord injury
1 Flicker of movement Cervicomedullary junction (above C3): extensive lesions
0 Total paralysis involve adjacent medullary centers vasomotor and
respiratory collapse neurogenic hypotension, apnea
SPINAL CORD INJURY unresponsiveness (difficult diagnosis) death (in absence
of ventilatory support).
C4-5 - quadriplegia with preserved respiratory function
(functional diaphragm)
C5-6 - sparing shoulder muscles (loss of biceps and
brachioradialis reflexes).
C7 - sparing biceps (loss of triceps reflex).
C8 - sparing triceps (paralyzed fingers and wrist flexion)
ipsilateral HORNER'S SYNDROME may occur at any cervical
level lesion.

Thoracic cord injury
Best localized by SENSORY LEVEL on trunk
nipples (T4), umbilicus (T10)
Syndrome of Acute Paraplegia or Quadriplegia Due to Complete BEEVOR SIGN - observe abdominal wall musculature and
Transverse Lesions of the Spinal Cord umbilicus by asking patient to interlock fingers behind
Trauma ->most frequent cause head in supine position and attempt to sit up:
Types of Injury lesions below T9 paralyze lower abdominal
Severe forward flexion injury ; muscles upward movement of umbilicus
Hyperextension injury ; (BEEVOR sign) + loss of lower superficial
Whiplash injury abdominal reflexes.
High-velocity missile penetrates the vertebral unilateral lesions movement of umbilicus to
canal and damages the spinal cord directly; normal side; absent superficial abdominal
Indirect consequence of a vascular mechanism. reflexes on involved side.
midline back pain is useful localizing sign.

Thoracic spinal cord transection
Causes paraplegia
Transection of the upper thoracic cord spares the upper
limbs but impairs breathing (involvement of intercostal
muscles) and may also cause paralytic ileus through
involvement of the splanchnic nerves.
Transection of the lower thoracic cord spares the
abdominal muscles and does not impair breathing.

NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters 3

DISEASES OF THE SPINAL CORD Types of incomplete injuries
The main syndromes to be considered are: i) Central Cord Syndrome
(1) a complete or almost complete sensorimotor ii) Anterior Cord Syndrome
myelopathy that involves most or all of the ascending and iii) Posterior Cord Syndrome
descending tracts (transverse myelopathy) iv) Brown Sequard Syndrome
(2) a painful radicular syndrome (segmental radiculopathy) v) Cauda Equina Syndrome

Transverse Myelopathy 1. Central Cord Syndrome :
When spinal cord transection syndrome arises gradually Typically in older patients
rather than suddenly, e. g., because of a slowly growing Hyperextension injury
tumor, spinal shock does not arise. Compression of the cord
The transection syndrome in such cases is usually partial, anteriorly by osteophytes and
rather than complete. posteriorly by ligamentum flavum
Progressively severe spastic paraparesis develops below Also associated with fracture
the level of the lesion, accompanied by a sensory deficit, dislocation and compression
bowel, bladder, and sexual dysfunction, and autonomic fractures
manifestations (abnormal vasomotor regulation and More centrally situated cervical
sweating, tendency to decubitus ulcers). tracts tend to be more involved hence
Usually seen in degenerative changes with central canal flaccid weakness of arms > legs
stenosis Perianal sensation & some lower extremity movement and
sensation may be preserved

Classic Central Cord
most common of INCOMPLETE SCI syndromes!
Etiology: neck hyperextension (esp. in patients with
spondylosis) cord compression between bony bars
anteriorly and thickened ligamentum flavum posteriorly
cord hypoperfusion in watershed distribution (mostly
central portion of cord central gray and most central
portions of pyramidal & spinothalamic tracts).
Segmental Radiculopathy central cord syndrome is an ischemic lesion (frequently no
Radiculopathy / myelopathy due to compression by mass radiologically identifiable fractures!!!) - neurologic changes
of disc material: tend to improve with time!
herniation into lateral recess or neural foramen
(posterolateral herniation) spinal root Syringomyelia
compression. Fluid filled cavitation in the center of the cord
herniation into spinal canal (central herniation) Cervical cord most common site
spinal cord compression (in cervical thoracic Loss of pain and temperature related to the
region) or cauda equina compression (in crossing fibers occurs early
lumbosacral region). cape like sensory loss
Weakness of muscles in arms with atrophy and
hyporeflexia (AHC)
Later - CST involvement with brisk reflexes in the
legs, spasticity, and weakness
May occur as a late sequelae to trauma
Can see in association with Arnold Chiari malformation


Roots above C8 exit above corresponding vertebral body;
remaining roots exit below their respective vertebral bodies

2. Anterior cord Syndrome:
Due to flexion / rotation
Anterior dislocation /
compression fracture of a
vertebral body encroaching the
ventral canal
Corticospinal and spinothalamic

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 tracts are damaged either by direct trauma or Later, severe radicular sensory deficits, affecting all
ischemia of blood supply (anterior spinal arteries) sensory modalities, arise at L4 or lower levels.
Clinically: Lesions affecting the upper portion of the cauda equina
Loss of power produce a sensory deficit in the legs and in the saddle
Decrease in pain and sensation below lesion area.
Dorsal columns remain intact There may be flaccid paresis of the lower limbs with
areflexia; urinary and fecal incontinence also develop,
3. Posterior Cord Syndrome: along with impaired sexual function.
Hyperextension injuries with With lesions of the lower portion of the cauda equina, the
fractures of the posterior sensory deficit is exclusively in the saddle area (S3S5), and
elements of the vertebrae there is no lower limb weakness, but urination, defecation,
Clinically: and sexual function are impaired.
Proprioception affected ataxia Tumors affecting the cauda equina, unlike conus tumors,
and faltering gait produce slowly and irregularly progressive clinical
Usually good power and sensation manifestations, as the individual nerve roots are affected
with variable rapidity, and some of them may be spared
4. Brown Sequard Syndrome: until late in the course of the illness.
Hemi-section of the cord
Either due to penetrating Examination and Management of the Spine-Injured Patient
injuries: The level of the spinal cord and vertebral lesions can be
i) stab wounds determined from the clinical findings.
ii) gunshot wounds Diaphragmatic paralysis occurs with lesions of the upper
Fractures of lateral mass of three cervical segments (an unrelated transient arrest of
vertebrae breathing is common in severe head injury).
Clinically: Complete paralysis of the arms and legs usually indicates a
Paralysis on affected side (corticospinal) IPSILATERAL fracture or dislocation at C4-C5.
Loss of proprioception and fine discrimination (dorsal If the legs are paralyzed and the arms can still be abducted
columns) IPSILATERAL and flexed, the lesion is likely to be at C5-C6
Pain and temperature loss on the opposite side below the Paralysis of the legs and only the hands indicates a lesion
lesion (spinothalamic) CONTRALATERAL at C6-C7
The level of sensory loss on the trunk, determined by
perception of pinprick, is an accurate guide to the level of
the lesion
In all cases of SCI our primary concern is that movement
(especially flexion) of the cervical spine be avoided.
The patient should be placed supine on a firm, flat surface
(with one person assigned, if possible, to keeping the head
and neck immobile)
Have the patient remain on the board until a lateral film or
a CT or MRI of the cervical spine has been obtained.
A neurologic examination with detailed recording of
motor, sensory, and sphincter function is necessary to
follow the clinical progress of SCI.

If a cervical spinal cord injury is associated with vertebral
Conus syndrome dislocation, traction on the neck is necessary to secure
Due to a spinal cord lesion at or below S3, is also rare. proper alignment and maintain immobilization.
It can be caused by spinal tumors, ischemia, or a massive This is best accomplished by use of a halo brace, which, of
lumbar disk herniation. all the appliances used for this purpose provides the most
An isolated lesion of the conus medullaris produces the rigid external fixation of the cervical spine.
following neurological deficits: This type of fixation is usually continued for 4 to 6 weeks,
Detrusor areflexia with urinary retention and overflow after which a rigid collar may be substituted.
incontinence (continual dripping)
Fecal incontinence - Impotence Halo Brace
Saddle anesthesia (S3S5) - Loss of the anal reflex

Cauda equina syndrome
Involves the lumbar and sacral nerve roots, which descend
alongside and below the conus medullaris, and through
the lumbosacral subarachnoid space, to their exit
foramina;
a tumor (e. g., ependymoma or lipoma) is the
usual cause.
Patients initially complain of radicular pain in a sciatic
distribution, and of severe bladder pain that worsens with
coughing or sneezing.

NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters 5

Spinal Cord Tumors Spasticity is only rarely as severe as that
Complete or partial spinal cord transection syndrome produced by extramedullary tumors.
(including conus syndrome and cauda equina syndrome) is
often caused by a tumor. High cervical tumors
Spinal cord tumors are classified into three types, based on can produce bulbar manifestations aswell as
their localization fasciculations and fibrillations in the affected
Extradural tumors (metastasis, lymphoma, limb.
plasmacytoma) Extramedullary tumors are much more common
Intradural extramedullary tumors (meningioma, overall than intramedullary tumors.
neurinoma) Tumors at the level of the foramen magnum
Intradural intramedullary tumors (glioma, (meningioma, neurinoma)
ependymoma) often initially manifest themselves with pain,
Extradural neoplasms paresthesia, and hypesthesia in the C2 region
tend to grow rapidly, often producing progressively severe (occipital and great auricular nerves). They can
manifestations of spinal cord compression: spastic paresis also cause weakness of the sternocleidomastoid
of the parts of the body supplied by the spinal cord below and trapezius muscles (accessory nerve).
the level of the lesion, and, later, bladder and bowel
dysfunction. Dumbbell tumors (or hourglass tumors)
Pain is a common feature. So called because of their unique anatomical configuration
Dorsally situated tumors mainly cause sensory These are mostly neurinomas that arise in the
disturbances; lateral compression of the spinal cord can intervertebral foramen and then grow in two directions:
produce BrownSquard syndrome into the spinal canal and outward into the paravertebral
space.
Intradural Extramedullary Tumors They compress the spinal cord laterally, eventually
Most commonly arise from the vicinity ofthe posterior producing a partial or complete BrownSquard syndrome.
roots
They initially produce radicular pain and paresthesiae.
Later, as they grow, they cause increasing compression of
the posterior roots and the spinal cord
The result is a progressively severe spastic paresis of the
limbs, and paresthesiae (particularly cold paresthesiae) in
both limbs
The sensory disturbance usually ascends from caudal to
cranial until it reaches the level of the lesion.
The spine is tender to percussion at the level of the
damaged nerve roots, and the pain is markedly
exacerbated by coughing or sneezing.
Hyperesthesia is not uncommon in the dermatomes
supplied by the affected nerve roots; this may be useful for
A. Extradural neoplasm
clinical localization of the level of the lesion.
B. Extradural neoplasm
As the spinal cord compression progresses, it eventually
C. Intradural Extramedullary Tumor
leads to bladder and bowel dysfunction.
D. Intradural Intramedullary Tumor
Ventrally situated tumors can involve the anterior nerve

roots on one or both sides, causing flaccid paresis, e. g., of
--END--
the hands (when the tumor is in the cervical region).


Reference:
Intradural Intramedullary Tumors
- Dr. Sengs powerpoint lecture
Can be distinguished from extramedullary tumors by the
following clinical features:
They rarely cause radicular pain, instead causing
atypical (burning, dull) pain of diffuse
localization.
Dissociated sensory deficits can be an early
finding.
Bladder and bowel dysfunction appear early in
the course of tumor growth.
The sensory level (upper border of the sensory
deficit) may ascend, because of longitudinal
growth of the tumor, while the sensory level
associated with extramedullary tumors generally
remains constant, because of transverse growth.
Muscle atrophy due to involvement of the
anterior horns is more common than with
extramedullary tumors.

6 NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters